Monday, February 28, 2011

I have a relative who likes to send me everything she reads that has the word doctor somewhere in the article, assuming that it's relevant to what I do.

Today she sent me an article from the New York Times (link here) about radiation and infants and asked me if I ever give x-rays to infants without protecting their gonads (and telling me if I do, I should stop).

I sent her back an e-mail asking her to please, finally, take me off of her e-mail list, and that, no, I don't do anything to infants because I only deal with adult patients, and I also don't administer x-rays because I actually went to medical school and have a degree in medicine, and I am not an x-ray technician.

I'd like to think the tone of my e-mail was more pleasant than the tone of my description of my e-mail, but it probably wasn't. I suppose lawyers and other folks have this problem too, but it's kind of frustrating to me that no matter how many times I explain to someone what internal medicine is, and what I do -- in a very general sense -- they still think that every doctor does everything, and that of course I'm not only an internist but I'm also a neurosurgeon and a gynecologist and a child psychiatrist and an insurance plan administrator and a podiatrist and a dentist and a pharmaceutical sales representative and a fitness instructor.

I don't know any more about the problem with your eye than Google does. Really, I don't. I don't know what you should and shouldn't do when you're pregnant, and I don't know what milestones your infant should be hitting at x number of months. There is enough that we have to learn and are expected to know that I don't read journal articles about veterinary nutrition in my spare time. I read about right bundle branch blocks and left bundle branch blocks (try saying bundle branch block ten times fast) and try to be a better doctor to the patients I do see, for the problems I am supposed to know something about.

(But I will say one thing about radiation. That article is fairly frightening. And, especially since no resident I know is paid per test ordered, I would hope that radiation on infants is only being used when necessary, and that the proper precautions are taken.)

(Editing to add after reading the first comment below-- nope, didn't mean to imply that. Not really sure what I meant, as I re-read it. I mean, I know what I was thinking-- residents especially have no incentive to order unnecessary tests. But, obviously, no one should be ordering unnecessary tests, on adults or on infants, involving radiation or not involving radiation, whether they're making money on them or not. Ever. Anybody. Period. I think my subconscious may have been expressing some doubt about whether every doctor puts all financial motivation aside when ordering tests on patients, but I didn't mean to imply anything. Watch your bills. Get second opinions.)

Saturday, February 26, 2011

Just went on a field trip to visit my patient in rehab. Thanks to the commenters on the previous post for encouraging it. He appreciated it, and I felt good about myself for making the effort.

You'd think there would be more opportunities for us to feel good about ourselves, since we are, in theory, helping people.

I'm being sort of glib there. Of course there are people I feel like I help, and there are moments in most days where I feel like I'm doing good. It's just more natural to dwell on the other moments, when I feel like I'm in over my head, or there's not much anyone can do. I have a patient who's terminal-- rapidly terminal-- and as much as we've tried to explain things to the family, it didn't really click until today. The specialist was using words like "treat," which the family heard as "cure," and we all knew they were clinging onto false hope, but we were trying to be so gentle in explaining what was going on that it wasn't really registering. (I happened to catch an episode of Parks and Recreation the other night where the Rashida Jones character was broken up with in such a gentle way that she didn't even realize it -- I very strongly felt the parallel to this situation.) And then today the patient got a little worse, and there was a little less we were able to say we can do, and... suddenly the family starting asking more serious questions. And it all clicked. And they fell apart. And there was very, very little we could do except answer their questions and give them as much time as we could.

Thursday, February 24, 2011

"I don't want her to be an interesting case. I want her to be better."

"Yeah, I'm sorry. Best I can do is 'interesting case.'"

And then the mother burst into tears.

And the attending left to deal with her office hours and I had to deal, alone, with this family that's just been told their daughter is dying... but at least her case is interesting.

Not that I can promise that I would have necessarily not said what the attending said. We swoop in on these people's lives. To us, too often they're 'interesting cases' more than they are 'actual people.'

We sent a patient to rehab yesterday, and as he was being wheeled out he asked if I would come visit him. "Oh, we don't really get to that side of the hospital too often." Is that the best I could do? Probably not. I could probably go visit him for a few minutes while he's in rehab. It probably wouldn't kill me. But I probably won't. And I don't think that makes me unique.

I'm trying to understand why I didn't just say I'd go visit him, and actually mean it. He's a nice elderly man, we spent about 45 minutes talking about his life, while I was talking his history. It was a slow afternoon, I had time. So we talked. He's alone. I could visit him. And maybe it's just the culture -- here specifically or maybe at any hospital, I really don't know. But to walk out the door, across the street, over to the rehab side and... and answer questions about why I'm there? If someone from rehab came over to our side to visit a patient, it would probably be totally fine. No one would necessarily assume he was trying to interfere or take over the case. It would be fine.

Part of it is time, sure. It's probably 20 minutes to get over there, visit a patient, and then come back-- there aren't 20 minutes to do that-- except there would be, if I wanted there to be, I guess-- although we never leave the building during a shift, and I don't think I'd feel comfortable going over there during a shift, so I'd be adding 20 minutes onto my day at one end or the other, and-- why am I trying to rationalize this? The patients feel closer to us than we feel to them, that's just what it is, right? I can't get attached, because most them die. Even if not now, then soon. The 'interesting case' is probably going to die. It is sadder for her to be a person than for her to be an 'interesting case.'

"I leave it to you," the attending said in his note about the interesting case. "Do whatever you think we should do." I panicked. This isn't guidance. I've almost gotten to the point where I know how to manage uninteresting cases on my own. Boring, standard cases that we see over and over again, I can handle. But interesting cases, I need help. I asked for help. I asked every specialist we saw for help on this one. "Keep doing what you're doing," "I'd get a chest x-ray," "seems like you should check the electrolytes," etc. She's stable, and slightly less interesting. So I've probably done my job. I don't know. What is my job if there is no medical solution? Is it to pretend we're helping? Is it to comfort them? Is it to visit my patient in rehab?

Tuesday, February 22, 2011

1. There are two patients who need an MRI, and it's already 3:15. Who gets it?

A. The young man without health insurance.

B. The old woman on Medicare.

C. Neither, because the MRI machine isn't working.

D. Neither, because not only do we think the MRI machine isn't working (we can never be sure), it's already 3:15 and you know the technicians leave at exactly 5:00-- so it's not worth taking the risk that we get the patient down here and prepped only to realize we don't have enough time to finish the test before the clock runs out. So let's just leave it for tomorrow morning. Or the next day. Whenever. You know, who cares.

2. It seems like there's a patient who wasn't included on the sign-out list for night float. And you're night float. What do you do?

A. Call the resident who did the sign out, and see if she accidentally forgot to include the patient. Get the information over the phone and add the patient to your list.

B. Check the chart yourself, since there's no reason to necessarily bother a resident who just worked a 14-hour shift. Get the information from the chart and add the patient to your list.

C. E-mail the entire residency program, including all of the attendings, complaining that some residents are sloppy with their sign-outs, and recommend that your colleague be kicked out of the program. Deny sending the e-mail when confronted the next morning. Ignore the patient, out of spite, because she wasn't included on the sign-out list.

D. There's a patient who wasn't included on the sign-out list? Shhhhh. What patient? Shhhh. There is no patient.

3. The attending asks you why your patient's labs haven't been checked in six hours, even though she says she ordered them stat this morning. You don't remember seeing any order like this, but you also don't feel like checking the chart. Who do you blame?

A. Phlebotomy.

B. The nurses.

C. Your intern.

D. The fellow.

4. Your co-resident has a family emergency and wants to switch days off. You had no plans for either day (or any day, now that you think about it). What do you do?

A. Offer to switch.

B. Offer to switch, if he'll take three of your overnight shifts as compensation.

C. Offer to switch, and then take the day off anyway and deny you ever offered to switch, or have any idea what your co-resident is talking about.

D. Send an e-mail to the entire residency class telling them how lazy your co-resident is.

5. Your pager goes off. You are sleeping. Which of the following things do you do to your pager?

The son interrupts. "You said she was getting a chest x-ray. No one came. So I picked up the phone and said she couldn't breathe. That, you come running for."

"Well of course we come running--"

"But for her x-ray--"

"She'll get her x-ray."

"She'll get it now," he said.

"No, she'll get it when she needs to get it, and we've taken care of actual emergencies. And for you to call a rapid response, and get everyone on the floor to stop treating the patients who need them, for no reason--"

The code leader stepped in between us. She turned to the son, calmly.

"We're going to call security, and we're going to have you escorted from the hospital. Your mother will get her chest x-ray when it's appropriate. You cannot call a rapid response just to get our attention."

Everyone walked out.

The code leader called security.

Security laughed.

The son's still there.

I don't know what's going to happen if his mother really needs a rapid response, because no one's going to believe him.

Thursday, February 17, 2011

Sometimes you start a new rotation and next thing you know, it's three days later. Yikes. I should probably sleep now while I have the chance. An "early" day. Great. Last "early" day on Tuesday I was at the hospital until 10.

I got tapped on the shoulder by someone from the medical documentation office. I'd forgotten these exciting conversations when I was at the outpatient clinics. The documentation people are the ones who read our notes and try to figure out how much they can massage our diagnoses into more things to bill the insurance company for.

"You said in your note that the patient was complaining of abdominal pain. Would you say that was chronic abdominal pain?"

"I don't know."

"But you'd be willing to write the word chronic in the note?"

"Uh, sure."

"Great. Would you say there was a possibility of Crohn's disease?"

"I don't know."

"But you thought about whether she could have Crohn's disease."

"I guess the thought crossed my mind, but her symptoms didn't match up with Crohn's disease."

"But you would say you evaluated her for Crohn's disease?"

"I don't know."

"Did you make an evaluation that she did or did not have Crohn's disease?"

Monday, February 14, 2011

Daughter comes in with her 60 year old mother. Neither speaks much English, but the daughter speaks a little bit. I ask her what language they need on the translator phone. She names a fairly obscure language. So I dial the number and get someone on the line.

And I notice the daughter is doing all the talking-- answering all of the questions on her mother's behalf.

"I'd like your mother to try answering the questions herself."

"Oh, she doesn't speak [this language]."

"What?"

"Yeah, I speak it, but she doesn't."

"Why didn't you tell me a language she speaks?"

"You didn't ask."

"Can we switch to a language she speaks?"

"She doesn't speak anything."

"What?"

"She doesn't know any languages."

"What? How do you communicate?"

"Oh. She speaks [another language]."

"I thought you just said she doesn't know any languages."

"Yes. She doesn't read it, she just speaks it."

"Okay, well let's switch to the language she speaks."

"Oh, I hate that language."

"Yes, but your mother is the patient."

"I refuse to speak [that other language]. Goodbye."

And the daughter leaves.

And I get the other interpreter on the phone.

And we discover the mother has an entirely different set of problems than the daughter was telling me she had.

And people wonder why it takes three times as long to see a clinic patient who needs to use the translator phone.

"That's really not how a sinus infection works. You want me to take a minute to explain what a sinus infection is?"

"No. I just want a decongester."

"A decongestant?"

"Sure."

"I'm going to need to examine you first."

"Sure. I brought a urine sample from home."

****

I saw the string of comments on my post from earlier in the week about the patient who wanted a second opinion-- and wouldn't even tell me what was wrong with him-- and I actually felt like commenter WarmSocks got a pretty rough ride in there, maybe more than he or she deserved. I think WarmSocks is absolutely right that I didn't help the patient very much-- and at the end of the day, that's a failure on my part, absolutely. I don't know that sitting down and trying to explain what a second opinion entails would have made a difference-- I suspect it wouldn't have made any difference at all, and he still would have refused to help me figure out his problem and I wouldn't have gotten any further than I did-- but I'm pretty sure I didn't try hard enough to see if there was any hope of getting anything from the guy.

Fact is, it's really easy to lose patience when someone doesn't seem like they want to be helped. Especially at the end of a long day, but even at the beginning of a long day. There's only so much we can do. I'd say at least 50% of the patients I see admit, on any sort of questioning, that they're either not taking their prescribed medication, or they're not taking it correctly. Some of it is surely the fault of whoever prescribed the medication in the first place, by either not explaining the instructions or not making sure the patient has a plan to even get the prescription. But some of it has to fall on the patient. And if someone isn't going to help themselves, it's hard to get all that motivated to spend an hour-- delaying everyone else-- while you try to see if there's anything beneath what seems like craziness on the surface.

Part of the problem with the clinics we have in residency-- and this isn't the fault of the residency program, or anyone's fault, it's just a fact of the schedule-- is so many of our patients are one-offs. They see a different doctor each time they show up, we all have to start from the beginning, get their whole story, they're telling the same story every time they go to the doctor and there's no continuity of care, no one who knows them, no one who knows how they express themselves, what's really going on, etc.

They try for continuity when they can-- we encourage our patients to ask for us when they make an appointment and try to arrange their schedules to see us, if they can. But we're in clinic one, maybe two half-days a week-- some months more than that, and some months never in clinic at all-- so unless the patient happens to have a flexible schedule, non-urgent needs, and actually cares to see the same doctor again (many of them don't bother to try, either because they don't think it makes a difference, or didn't particularly care for the first doctor they saw), it doesn't happen. Maybe one in six patients I see are repeats. And the repeats, without a doubt, end up with better care. There's a difference between reading the notes in the chart and actually remembering that I saw this person, I talked to him, I know what his baseline is, and so I know if this new problem is actually a new problem, or it's not a problem at all.

"Your mother doesn't have diabetes. She needs the calories to keep up her strength.

"But I don't want her to get fat."

"She's 82 pounds. Please feed her more calories. That is priority number one."

"Except nothing too fattening, right?"

"Everything fattening."

"For me too?"

"No. For your mother."

"But why should she get to eat all the good stuff that I can't?"

"Because she's 95 and weighs nothing."

"How about sugar-free pudding?"

"Okay, let me start again..."

****

It's really hard to have these conversations with every patient. So I do lose patience. I try not to, but I do. We have residents who yell at patients. There are residents who've told patients specifically to request a different doctor next time. It's frustrating. It's hard. It's our job, and we get better at it over time, but it's still hard. Because it's not about the medicine-- in a lot of ways the medicine is easy. It's about communicating on their level, in ways they will understand. And that's not something they teach us.

Thursday, February 10, 2011

One right, one wrong.

Saw two patients yesterday at opposite ends of the "what the heck is wrong with them?" spectrum. One guy with a collection of seemingly-unrelated symptoms that seemed to make no sense together-- until it somehow popped into my head that maybe he had a rare syndrome that I think we heard about once in medical school-- and so I sent him for some tests, the results came back, and... amazing, I actually got it.

I don't want to overstate it, but it's moments like that when you remember why you wanted to be a doctor, and where some of the mental challenge comes in. I put the pieces together. The patient didn't come in wearing a sign telling me what he had. I didn't just do the standard workup and pass him along to the next guy. I figured out his illness, and now he'll get the right treatment. Not everyone would have figured it out, he just got lucky that I somehow remembered this thing from medical school. But that's sometimes the difference between good treatment and bad treatment-- you get lucky and get a doctor who knows this particular problem. Not trying to toot my own horn, there are a million issues I know nothing about and someone would be quite unlucky to get me as their doctor. But this time, I was right.

As opposed to the other guy I saw, who seemed to have come directly from a textbook. Every symptom we learn about for a certain condition (I'm trying to be appropriately discreet here), even the tiny ones. Every single one. It was as if he was reading the same checklist we were, and checking every box.

And then I ran the tests, certain of the diagnosis... and... not it.

What is it? Who knows. I don't. He's getting worse. Attending doesn't know either, which sort of makes me feel good, but then when I remember this is actually some patient's health we're dealing with, it's not so good. But at least it's not just me. I guess. I have no idea what this guy has, because every textbook would say he has something else.

One of my colleagues yelled at a patient in clinic yesterday, because the patient couldn't remember to call her "doctor." She was "nurse," she was "honey," she was "sweetie," but she was never "doctor." And finally-- and it was at the end of a very long shift-- she lost her cool, and told the patient she is a *doctor* and he needs to call her that.

This is a problem female residents have fairly often, and male residents have pretty much never. There is some segment of the population-- and it's not always the elderly patients-- who simply can't wrap their heads around a female doctor. Especially a young-looking female doctor. And, whether inadvertently or not, they keep addressing her as something-not-a-doctor. And if happens once, fine, but if it happens a dozen times a day I can imagine it starts to feel like something more personal, and I can see why someone can react.

I've had patients call me by my first name. And it's not like I'm doing anything to encourage that, but it doesn't really bother me. I don't take it as any sort of comment on my authority as a doctor or my qualifications or anything like that. They're not mistaking me for a candy striper.

But I think for women it's different. I think it ends up seeming like a sign of a lack of respect, and that they're not being taken seriously.

Personally, as long as the patients aren't calling me by a curse word, I'm fine with it...

Thursday, February 3, 2011

We had a simulation exercise today. Practice dealing with a (fake) patient who's quickly crashing, with a (fake) family member at her bedside fake freaking out and a (fake) intern making mistakes (part of the script) and nurses who need management and all sorts of other things-gone-wrong. Purposely designed to be a worst-case-scenario.

My patient died.

Most people's patients died, it's really not a big deal. Only a few people navigated through so that their patients survived. They say it's just practice, that it's not a reflection on whether we're good at this or not.

Wednesday, February 2, 2011

I'm very confused by the comments that are very confused about my post yesterday.

Maybe it's different in other hospitals, but we don't stay in one place all the time. We are constantly rotating through different teams, different attendings, different patients, different nurses-- we're in clinic, we're on the floors, we're everywhere. It's not like we stay in one place and attendings rotate through. Everyone is working with new people all the time. Everyone is seeing patients all day. Everyone is in this together.

I don't get the "limited" 80 hour work week comment either. I've never heard anyone try and make an argument that most attendings work longer hours than residents. I'm not saying attendings don't work hard, but attendings-- for the most part-- are not in the hospital anywhere close to 80 hours a week. They may round in the morning with us, and may round again later in the day, but they go home. They have days off.

I worked with this attending every day for three weeks, two months ago. We were together for maybe three hours a day, two months ago, for three weeks. As one of three people on a team that he was working with. I've seen him in clinic eight or nine times since then. Including two days ago. He is someone I've had actual conversations with. He is someone I would have felt comfortable asking for a recommendation letter. I'm not even asking that he remember my name-- although I would think he would remember my name-- but to not remember anything beyond a vague recollection that I look familiar seemed pretty ridiculous to me. "Where do I know you from?" Where do you think you know me from? For three weeks, two months ago, we rounded every day, twice a day, and talked about our patients. Since then, you see me in clinic every week. For me to realize that I'm basically no different than a stranger to him is sort of disappointing.

It's interview season, and they spend an awful lot of energy trying to sell the residency program-- this one and other ones, for sure-- as a place that ends up being like your family for three years, people know each other, people work well with each other, it's a community, blah blah blah. Obviously it's all recruiting garbage and none of what anyone says to get you to take any job at all is ever anything close to reality, but I can't believe that the two comments I received on the post were trying to say that I'm crazy to think that an attending would remember who I am after working together. I give credit to the nurses-- the nurses have to remember more people than any of us, they're constantly working with a different team of attendings, residents, patients, other nurses-- and they basically remember everyone's name and who they are. Is that more a function of their job and being able to do it than for an attending, who can just bark orders at people without having a clue who they are? Maybe. But as a human being-- not as an attending, or a resident, or a nurse, or a patient-- it seems like common humanity to try not to treat the people you work with as complete strangers.

At least fake it. At least smile and pretend to be friendly and know who everyone is. Wave. I don't know. Reciprocate. I think it's posturing more than anything else. "I'm an attending, why should I lower myself to a level where I know you? Why should I know you? You're not important, you're just a resident, you're interchangeable with any other resident, you're a cog in a wheel, now go get me lab results before I forget who you are again."

I sanity-checked the idea of the post with one of my colleagues, who told me a story. An attending, one night, had to come in from home to deal with one of her patients. The resident had mismanaged the case, and the attending came in, dealt with it, and then yelled at the resident for half an hour, telling her she had no idea what she was doing, she wasn't fit to be a doctor, all sorts of stuff. Left her in tears, left her worrying she was going to be kicked out of the program. Next morning, they're rounding, the resident feels terrible about what happened, the attending comes in, gathers the team for rounds, pulls the resident aside and says to her, "I'm so relieved to have you back this morning, you've really been doing a great job. Whoever was on last night was a train wreck, I should find out who she was. But you, you're great, I'm glad to be working with you."

She didn't know how to respond. Nor would anyone. Awaiting more comments to tell me how awesome the attendings are to even let me breathe their air...

Tuesday, February 1, 2011

Yesterday morning, I ran into one of the attendings I've worked with a whole bunch of weeks at a coffee shop a block away from the hospital. I said hello, friendly-- or at least as friendly as I can be at six in the morning.

He looks at me, no real recognition.

I try again. "Dr. Jones, hi."

"You look familiar," he says. "Where do I know you from?"

"I'm a resident. We were on floors together a couple of months ago. [My name]."

"Oh."

"We had that patient who dropped dead in the middle of the day...?"

"Yeah, sorry, I... I work with so many residents."

"Yeah, that's fine."

"Good luck with residency."

"Yeah, thanks."

Good thing I didn't ask this one for a recommendation letter. This is not an isolated incident, and it's not just about me. I don't know why it is that as residents, we can remember all of our attendings, but most of the attendings lose all memory of their residents three minutes after the rotation ends. And sometimes during the rotation. I know we look different without the white coats, and it would be hard completely out of context. But a block away from the hospital, at six in the morning, is not completely out of context, and if you work with someone for a few weeks-- seeing them every day, talking to them, interacting with them for a few hours a day for weeks-- you would think they would stick just a little, for a couple of months.

I think maybe it's a status thing. Patients remember the nurses, nurses don't really remember the patients. We'll have patients come in and tell a nurse, "oh, you were my nurse last time, in 2006," and the nurse will have no idea. Nurses remember the residents. I'll go back to a hospital after having rotated elsewhere for six months and the nurses will immediately remember who I am, and be friendly. I will usually remember most of them, but if I am being honest, they seem to remember me more than I remember them. Residents remember attendings, but attendings have no clue. Attendings, presumably, remember the people who run the hospital, who, I assume, have no idea who they are.

No one, of course, remembers the patients. Because no one in the hospital is lower status than the patients.